**POLICY NO.:** 86-68-700

**EFF. DATE OF POL.:** [Not specified]
**EFF. DATE OF END.:** [Not specified]
**AGENCY NO.:** [Not specified]
**ADD'L. PREMIUM:** $ [Not specified]
**RETURN PREMIUM:** $ [Not specified]

**Named Insured**

This endorsement is issued by that company named below which is the insurer under the policy designated above issued to the Named Insured and forms a part of said policy as of the effective date hereof, at the hour stated in the policy Declarations.

IT IS AGREED THAT IN ADDITION TO THE PREMIUM OTHERWISE DEVELOPED BY THE POLICY A FIXED BASIC CHARGE PER POLICY (NOT SUBJECT TO DISCOUNT) SHALL BE MADE FOR INCREASED LIMITS OF LIABILITY AS FOLLOWS:

**BODILY INJURY LIABILITY:**

EACH ADDITIONAL $100,000, OR FRACTION THEREOF,
PER OCCURRENCE, ABOVE $300,000. PER OCCURRENCE. $5.00

**PROPERTY DAMAGE LIABILITY:**

EACH ADDITIONAL $50,000, OR FRACTION THEREOF,
PER OCCURRENCE, ABOVE $50,000. PER OCCURRENCE. $5.00

THE ABOVE BASIC CHARGES APPLY FOR ONE YEAR OR LESS AND ARE NOT SUBJECT TO SHORT RATE ADJUSTMENT.

**PREMIUM:**
B.I. $35.00
P.D. $EXCEPT AUTO - $5.00

**ZURICH INSURANCE COMPANY**
AMERICAN GUARANTEE AND LIABILITY INSURANCE COMPANY

Countersigned: [Signature]
Form 116-G 50M 10-65
ATTACHED IN FACT

IBM 062372